Special Feature
By Stephen W. Crawford, MD
“Faith in the gods or in the saints cures one, hypnotic suggestion another, faith in a plain common doctor a third.”—William Osler, MD
Care of patients in the intensive care units is a demanding profession that increasingly is dependent on technology. We rely on electrocardiography, pulse oximetry, pressure transducers, ultrasonography, radiology, pharmacology, and numerous surgical techniques, among other systems, to diagnose, monitor, and treat our patients. However, these patients come to us with the gamut of emotions, passions, prejudices, beliefs, and values found in society. For many of them, the technology we take for granted is mysterious, mystical, and frightening. While we possess great faith in the ability of the technology to help us diagnose, palliate, and cure, patients often place their faith in God, religion, and prayer. This essay examines the basis for supporting the spiritual beliefs and needs of our patients, and the relevance of prayer in the ICU.
We may have the expertise to manipulate the impressive array of technologies in our hospitals, but I suspect we are not all that far removed from the beliefs of our patients. Who of us have not questioned whether there was a “higher power” that controlled the outcomes of our patients in the ICU, or has not told a patient or family to “Go ahead and pray: it can’t hurt”? Who has not at least muttered, “We’ve done all we can; it’s up to God, now,” and who of us has not been amazed by a miraculous recovery we would not have predicted?
Attitudes of Physicians about Religion in Patient Care
Empirical evidence suggests that religion remains very strong at all levels of society. However, training in medicine, and in critical care in particular, does not appear to foster an appreciation of the spiritual aspects of healing. Many patients desire more frequent and more in-depth discussions about religious issues with their physicians, but physicians generally do not discuss these issues with their patients.
King and Bushwick found that physicians rarely question patients about their religious beliefs.1 This lack of inquiry may be contrary to patients’ wishes and detrimental to patient care. They interviewed 203 family practice adult inpatients at two hospitals regarding their views on the relationship between religion and health. Many patients expressed positive attitudes toward physician involvement in spiritual issues. Seventy-seven percent said physicians should consider patients’ spiritual needs, 37% wanted their physicians to discuss religious beliefs with them more frequently, and 48% wanted their physicians to pray with them. However, 68% said their physician had never discussed religious beliefs with them.
Goldfarb examined the attitudes of medical students and patients toward religion and spirituality in the recovery process from substance abuse and general psychiatric disorders.2 Similar to the findings of King and Bushwick, cited above, this study found that the medical students responsible for treating substance abuse were significantly less religiously and spirituality oriented than the patients they treated, and that the students did not indicate that spirituality was an important component in the care of these patients.
Table 1
Table of contents
Demonstrated “effects” of prayer
1. lower blood pressure
2. better mental health
3. improved recovery from surgery
4. improvement in psychiatric symptoms
5. improved hospital course in coronary care unit
6. reduced electromyographic activity
Relationship between Spirituality and Health Status
Spirituality may play a role in maintaining health and in recovery from illness (See above Table). Studies have found that people who regularly attend religious services have lower blood pressure, better mental health, and better recovery from coronary artery bypass surgery.3-5 A controlled study in 1957 demonstrated effects of non-traditional, “spiritual” interventions. Parker showed that a program of regularly scheduled prayer, in contrast to random prayer, was as effective as individual psychotherapy in treating psychiatric problems.6
The most significant and intriguing study of prayer came from cardiologist Randolph Byrd in 1988.7 He randomized 393 patients admitted to the coronary care unit at San Francisco General Hospital to a protocol that was prospective and blinded to all physicians and patients. A prayer group (192 patients) was prayed for daily by Christian followers outside of the hospital. The control group (201 patients) received no intercessory prayer as part of the study.
There were no significant differences in age, duration of CCU or hospital stays, or primary cardiac or non-cardiac diagnoses. Surprisingly, the prayer group did statistically better by several criteria. The prayer group had fewer episodes of congestive heart failure (8% vs 20%), cardiopulmonary arrest (3% vs 14%), pneumonia (3% vs 13%), antibiotics (3% vs 17%), and intubation and ventilation (0% vs 12%) (P Physiologic Effects of “Non-Contact Therapeutic Touch”
The effects of prayer and other non-conventional healing modalities may have beneficial origins in realms other than “God.” Wirth has recently examined the effect of non-contact therapeutic touch (NCTT) in isolation and in combination with holistic healing techniques, and intercessory prayer on the healing rate of full thickness human dermal wounds using a randomized, double-blind, within subject, crossover design.8 The treatment group was compared to a group treated by “sham” practitioners. The protocol incorporated an integral biofeedback, guided imagery, and visualization/relaxation component in order to assess the influence of psycho-physiological factors on the healing process. The NCTT method is a non-religiously-based technique that is considered to be mediated by an energy exchange between the practitioner and subject. The practitioner positions his/her hands 2-6 inches from the subject to consciously attune, redirect, and balance the energy fields in areas of blockage or tension.
In this complicated, cross-over designed study, the control (“sham”) group displayed more rapid wound healing—opposite to the results expected by the investigators. They postulated that there may have been a “carry-over” effect of prior exposure to the NCTT among the control group. In a follow-up study, Wirth and colleagues demonstrated delayed autonomic nervous system changes and electomyographic changes associated with the NCTT and holistic healing techniques.9 Their findings support physiologic effects of these “healing” techniques. These authors do not claim a religious connection or deity is necessary or responsible for the effects.
Possible Explanations for the Effects of Prayer on Health
If we accept that there are effects of prayer and other “non-touch” healing techniques, how can we account for them? Conventional views have considered beliefs in healing prayer to be incompatible with rational modern thought, predicting their demise and explaining their persistence in terms of non-rational thinking, “special logics,” and psychological compartmentalization. However, attention to the actual beliefs of individuals often reveals them to be rationally ordered and empirically founded.10 Further, strong religious beliefs do not usually involve disbelief of medical knowledge.
A theoretical model that outlines various possible explanations for the healing effects of prayer include mechanisms that are defined on the basis of whether healing has naturalistic or supernatural origins and whether it operates locally or nonlocally.11 Most of the currently proposed hypotheses for understanding “absent” healing and other related phenomena (such as subtle energy, psi, consciousness, morphic fields, and extended mind) are probably no less naturalistic than the Newtonian, mechanistic forces of medicine. These nonlocal effects can be conceived of as naturalistic—that is, they are explained by physical laws that may be unbelievable or unfamiliar to most physicians but that are nonetheless becoming recognized as operant laws of the natural universe.
The precise mechanisms by which many “natural” medical pharmaceuticals produce beneficial effects remain unknown. The effects are accepted as real and based in physical sciences. The concept of the supernatural, however, is something altogether different, and is, by definition, outside of or beyond nature. The supernatural explanation may require a transcendent God who heals through means that transcend the laws of the created universe, and that are inherently inaccessible to and unknowable by science. Such an explanation for the effects of prayer merits consideration and, despite its unprovability by medical science, should not be dismissed out of hand.
Clinical Importance of Prayer and Spirituality in the ICU
Regardless of whether we believe in the beneficial effects of prayer in healing, care givers in the intensive care unit have an obligation to honor the beliefs of patients in prayer. Medicine and religion share a basic respect for persons. Many of our patients have religious beliefs. The nature of the physician-patient relationship underlies the professional’s obligation to respect each person.12
As a matter of pragmatism, religion and prayer serve important functions for the sick or dying patient,13 as summarized in Table 2. First, religion provides a theoretical backdrop in which to make sense of illness and mortality by understanding them as punishment, education, purification, sacrifice, or mystery, and it does so without denying the reality of these experiences. Second, it provides practical resources for coping with sickness, suffering, and mortality such as prayer, social support, and ritual actions directed at forgiveness, transcendence, and healing. And finally, it gives hope in the face of certain death.
Table 2
Functions of religion in illness
1. Provides a theoretical backdrop in which to make sense of illness and mortality by understanding them as punishment, education, purification, sacrifice, or mystery.
2. Provides practical resources for coping with sickness, suffering, and mortality.
3. Gives hope in the face of certain death.
We are well aware of the psychological benefits of religion and prayer. I have reviewed some of the data that support a physiological clinical benefit, as well. Beliefs in spiritual forces and religion, and the desire to use prayer in healing, is not counter to the goals of traditional medicine. These patient-centered beliefs and acts are complementary with our mission in the ICU. We may not understand the origins and mechanisms of the effects of religion and prayer, but to deny them does our profession and our patients a disservice.
“Nothing in life is more wonderful than faith—the one great moving force which we can neither weigh in the balance nor test in the crucible.”—William Osler, MD
References
1. King DE, Bushwick B. J Fam Pract 1994;39:349-352.
2. Goldfarb LM, et al. Am J Drug Alcohol Abuse 1996;22: 549-561.
3. Graham TW, et al. Behav Med 1978;1:37-43.
4. Wilson WP. Dis Nerv Syst 1972;33:382-386.
5. McSherry E. Care Giver 1987;4:1-13.
6. Parker R. Prayer Can Change Your Life. Englewood Cliffs, NJ, Prentice-Hall, 1957.
7. Byrd RC. Southern Med J 1988;81:826-829.
8. Wirth DP, Barrett MJ. Internat J Psychosomatics 1994;41:61-67.
9. Wirth DP, Cram JR. Internat J Psychosomatics 1994; 41:68-75.
10. Hufford DJ. J Med Philosophy 1993;18:175-194.
11. Levin JS. Altern Therap Health Med 1996;2:66-73.
12. Thomasma DC. Hosp Progress 1979;60:54-57,90.
13. Sevensky RL. Southern Med J 1981;74:745-750.
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Prayers offered by strangers had no effect on the recovery of people who were undergoing heart surgery, a large and long-awaited study has found.
And patients who knew they were being prayed for had a higher rate of post-operative complications like abnormal heart rhythms, perhaps because of the expectations the prayers created, the researchers suggested.
Because it is the most scientifically rigorous investigation of whether prayer can heal illness, the study, begun almost a decade ago and involving more than 1,800 patients, has for years been the subject of speculation.
The question has been a contentious one among researchers. Proponents have argued that prayer is perhaps the most deeply human response to disease, and that it may relieve suffering by some mechanism that is not yet understood. Skeptics have contended that studying prayer is a waste of money and that it presupposes supernatural intervention, putting it by definition beyond the reach of science.
At least 10 studies of the effects of prayer have been carried out in the last six years, with mixed results. The new study was intended to overcome flaws in the earlier investigations. The report was scheduled to appear in The American Heart Journal next week, but the journal’s publisher released it online yesterday.
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In a hurriedly convened news conference, the study’s authors, led by Dr. Herbert Benson, a cardiologist and director of the Mind/Body Medical Institute near Boston, said that the findings were not the last word on the effects of so-called intercessory prayer. But the results, they said, raised questions about how and whether patients should be told that prayers were being offered for them.
“One conclusion from this is that the role of awareness of prayer should be studied further,” said Dr. Charles Bethea, a cardiologist at Integris Baptist Medical Center in Oklahoma City and a co-author of the study.
Other experts said the study underscored the question of whether prayer was an appropriate subject for scientific study.
“The problem with studying religion scientifically is that you do violence to the phenomenon by reducing it to basic elements that can be quantified, and that makes for bad science and bad religion,” said Dr. Richard Sloan, a professor of behavioral medicine at Columbia and author of a forthcoming book, “Blind Faith: The Unholy Alliance of Religion and Medicine.”
The study cost $2.4 million, and most of the money came from the John Templeton Foundation, which supports research into spirituality. The government has spent more than $2.3 million on prayer research since 2000.
Dean Marek, a chaplain at the Mayo Clinic in Rochester, Minn., and a co-author of the report, said the study said nothing about the power of personal prayer or about prayers for family members and friends.
Working in a large medical center like Mayo, Mr. Marek said, “You hear tons of stories about the power of prayer, and I don’t doubt them.”
In the study, the researchers monitored 1,802 patients at six hospitals who received coronary bypass surgery, in which doctors reroute circulation around a clogged vein or artery.
The patients were broken into three groups. Two were prayed for; the third was not. Half the patients who received the prayers were told that they were being prayed for; half were told that they might or might not receive prayers.
The researchers asked the members of three congregations — St. Paul’s Monastery in St. Paul; the Community of Teresian Carmelites in Worcester, Mass.; and Silent Unity, a Missouri prayer ministry near Kansas City — to deliver the prayers, using the patients’ first names and the first initials of their last names.
The congregations were told that they could pray in their own ways, but they were instructed to include the phrase, “for a successful surgery with a quick, healthy recovery and no complications.”
Analyzing complications in the 30 days after the operations, the researchers found no differences between those patients who were prayed for and those who were not.
In another of the study’s findings, a significantly higher number of the patients who knew that they were being prayed for — 59 percent — suffered complications, compared with 51 percent of those who were uncertain. The authors left open the possibility that this was a chance finding. But they said that being aware of the strangers’ prayers also may have caused some of the patients a kind of performance anxiety.
“It may have made them uncertain, wondering am I so sick they had to call in their prayer team?” Dr. Bethea said.
The study also found that more patients in the uninformed prayer group — 18 percent — suffered major complications, like heart attack or stroke, compared with 13 percent in the group that did not receive prayers. In their report, the researchers suggested that this finding might also be a result of chance.
One reason the study was so widely anticipated was that it was led by Dr. Benson, who in his work has emphasized the soothing power of personal prayer and meditation.
At least one earlier study found lower complication rates in patients who received intercessory prayers; others found no difference. A 1997 study at the University of New Mexico, involving 40 alcoholics in rehabilitation, found that the men and women who knew they were being prayed for actually fared worse.
The new study was rigorously designed to avoid problems like the ones that came up in the earlier studies. But experts said the study could not overcome perhaps the largest obstacle to prayer study: the unknown amount of prayer each person received from friends, families, and congregations around the world who pray daily for the sick and dying.
Bob Barth, the spiritual director of Silent Unity, the Missouri prayer ministry, said the findings would not affect the ministry’s mission.
“A person of faith would say that this study is interesting,” Mr. Barth said, “but we’ve been praying a long time and we’ve seen prayer work, we know it works, and the research on prayer and spirituality is just getting started.”
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I was startled awake at 3:40 am by a loudspeaker blaring “Code Blue … Code Blue.”
As the hospital’s newly hired chaplain intern, I’d been sleeping in the overnight room. Stumbling out of bed and groggily changing out of my pajamas, I made sure to put on my hospital badge.
I made my way to the hospital’s “Z” building, where the ICU was located, and took the elevator to the fourth floor. The elevator opened onto a row of doorways, each decorated with a red warning sign: “Stop! Do Not Enter. Authorized Staff Only.”
I picked one and went through.
I’d guessed right: At the far end of a hallway, a group of gowned nurses swarmed around a woman lying in a hospital bed, her hospital robe trailing off to one side as they worked on her.
I approached the group, feeling a bit intimidated and uncertain of my role.
“Sixteen minutes ago, her heart stopped,” someone told me. Moving closer to the patient, I saw that she was a short, slightly plump woman about sixty-five years old. With a shock of disbelief, I realized that she was one of the patients I’d talked to earlier that evening. I remembered that she’d lapsed into and out of consciousness. She had asked if I would say the Lord’s Prayer with her, then had immediately fallen asleep.
The nurses were performing chest compressions–thrusting vigorously against the woman’s torso as her small body bounced in the bed like a pummeled rag doll. Every few minutes, a new nurse would step up to take a turn.
Despite my previous experience as a hospice chaplain, I’d never before seen the process of trying to revive a patient in cardiac arrest. But I’d heard hospice nurses encouraging patients to sign the Do Not Resuscitate paperwork, warning of the broken ribs and severe pain that follow a successful resuscitation. Now, seeing this scene, I vividly understood why.
As heroic as the nurses’ efforts were, they were also clearly hopeless. This brutal scene seemed like such a violation of the patient’s dignity–a denial of the sacredness of the moment of death. Unable to watch, I took a seat far back in the nursing station, mentally repeating the soothing thought It’s okay…She’s already dead…It’s okay…She’s dead.
“Here comes Dr. Robertson,” someone said. Up walked a nervous-looking young man wearing thick glasses, his hair rumpled and his white hospital gown creased and wrinkled. He looked like he’d just been wakened from a deep sleep.
The nurses looked at him expectantly. They clearly wanted him to call the time of death, but he stood frozen in place, looking bewildered. It was obvious to me that he, too, was a newbie.
The nurses kept up their efforts at resuscitation, their eyes locked not on the patient but on the doctor.
Eventually, two nurses got fed up. They ripped off their protective gowns and walked away briskly.
“I need to go take care of a living patient,” one said loudly.
The others continued the chest compressions for another ten minutes; finally Dr. Robertson made the call. All the frantic activity stopped. The patient lay there, her chest covered with dark bruises.
The code had lasted an excruciating forty minutes.
One of the nurses had heard a rumor that a family member was waiting; she motioned for the doctor to go find them. Still looking bewildered, he started to wander down the hall.
“Do you want me to go with you?” I asked, wanting to offer him some support.
He paused, then said, “Yes.”
Together, we walked out to the darkened waiting room. No one was there. We stood there for a minute, waiting to see if anyone would show up.
“Sorry,” said the doctor. I took this as an apology for wasting my time.
“It’s okay,” I said. “I needed to be here anyhow.”
He headed back towards the ICU.
I started to go to the elevator–but found I couldn’t leave. I walked back and caught up with the doctor outside the ICU door.
“Sir, could I say a prayer for the patient?” I asked. Again, he seemed startled and at a loss. I found myself wondering how much experience this young doctor had had in the hospital or with real patients.
A nurse motioned me to go in, so I gowned up again and walked into the patient’s room.
Three nurses hovered by the woman’s bed, removing the tubes from her throat, packing away the heart monitor and refastening her gown.
“Would it be all right if I pray for her?” I asked.
They all looked up. A pause, then the male nurse nodded.
“Would you join me?” I asked.
We all joined hands. Theirs were hot to the touch–probably from all their hard work this past hour, I thought to myself.
They joined me in reciting the Lord’s Prayer. For a little while, we were all still. Afterwards, they nodded to me in appreciation.
A few hours later, I was paged again. The woman’s family had arrived.
She lay still in the hospital bed, her gown and blanket neatly in place, her lifeless form now encircled by her husband, her sister, her two teenage children and her dad. Her name, they told me, was Lisa. She had been the CEO of a large religious agency with considerable power and influence in the community.
They wept and dabbed their eyes with tissues. We joined hands and prayed together for Lisa.
Afterwards, her sister turned to me.
“They told me she died peacefully,” she said.
Stunned, I remembered the Code Blue I’d witnessed, and couldn’t find the words to answer.
Stephen W. Leslie is a hospital chaplain. This piece was originally published in Pulse — voices from the heart of medicine, and is reprinted with permission.
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